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Intravesical tape removal simple technique
Case Report
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A simple technique for intravesical tape removal

Case Report by Stavros Charalambous - Chisovalantis Tountziaris - Charalambos Karapanagiotidis - Charalambos Thamnopoulos Papathanasiou - Vasilios Rombis

Department of Urology, “Hippokratio” General Hospital of Thessaloniki - Thessaloniki, Greece

Abstract: The tension-free vaginal tape (TVT) procedure has become the most frequently performed surgical technique for the treatment of stress urinary incontinence with cure rates reported at greater than 85%.1-3 Nevertheless, these excellent results are associated with specific complications such as bladder perforation 2-4 and vaginal, urethral and bladder erosion.5-8 Any undetected perforation or gradual erosion of the bladder wall may lead to a delayed recognition of an intravesical mesh. Herein, we describe a novel technique concerning mesh removal which requires minor instrumentation and results in the effective resection of intravesical tape.
Key words: Intravesical, Sling, Stress urinary incontinence, Tension-free vaginal tape.


CASE REPORT

A 63-year-old woman presented with recurrent urinary tract infections and dysuria, six months following a TVT procedure performed elsewhere. A physical examination revealed no abnormalities. A cystoscopy was performed and an intravesical mesh was identified entering just behind the right ureteral orifice and exiting from the right side of the bladder dome. The patient was then prepared for mesh removal. A 26 Fr resectoscope was introduced into the bladder and subsequently reached the tape. The mesh was resected in the same way as a deep resection of a bladder tumor, with the loop in constant contact with the bladder wall (Fig. 1). images

Primarily, an incision was made at the exit point of the bladder dome following adequate filling of the bladder, in order for the tape to be stretched. The same procedure was repeated at the point of tape entrance adjacent to the trigone, and the resectoscope subsequently withdrawn. A 26 Fr cystoscope was introduced into the bladder and the free piece of tape was grasped and removed intact via the sheath of the cystoscope (Fig. 2). images

The patient had an uneventful recovery. A follow-up cystoscopy, performed one month postoperatively, showed no evidence of a mesh or other abnormality. Follow-up data, one year post surgery, showed no signs of SUI recurrence.

DISCUSSION

Bladder perforation during insertion of TVT is a common operative complication with rates varying from 5 to 19%.2-4 However, if the condition is recognized intraoperatively, repositioning of the passer and drainage of the bladder for 24-48 h are the sole methods required for resolution of the problem. Therefore, a cystoscopy using a 70° angle is necessary to carefully inspect the entire surface of the bladder. In addition, full vesical distention is necessary, as folds of the bladder mucosa may conceal the tape. In addition, submucosal placement of the tape must not go unrecognised.

However, an intravesical mesh may be detected during a late cystoscopy in a patient experiencing recurrent urinary track infections or hematuria following a TVT procedure. This complication, occurring and remaining unidentified at the time of surgery or developing by gradual penetration of the bladder wall, represents an operative challenge. Several approaches to this problem have been proposed. Volkmer et al.8 proposed an open suprapubic approach with cystotomy for tape removal. Jorion described a method using a laparoscopic grasper via a suprapubic trocar using a transurethral nephroscope for inserting a laparoscopic scissors to cut the tape.9 Baracat et al.10 performed the excision in a similar fashion. Kielb and Clemens described a technique, which uses a laparoscopic scissors via a suprapubic trocar and a cystoscope to visualize and grasp the tape.11 In an attempt to reduce the invasiveness and morbidity associated with the procedure, Giri et al.12 in addition to Hodroff et al.13 reported and described cases treated with transurethral holmium laser excision.

Our technique uses a resectoscope and a cystoscope, common transurethral instrumentation, which are easily accessible in all urological departments. We believe the described technique in the present study should represent the initial approach for the removal of an intravesical mesh.



CONCLUSIONS

Urologists should exercise caution concerning cases with persisting symptoms resulting from lower urinary tract infection following TVT surgery, due to the possibility of the presence of an intravesical mesh. In such cases, the technique described herein can be easily performed and is less invasive, ensuring low morbidity.

REFERENCES

  1. Rezapour M, Ulmsten U. Tension-free vaginal tape (TVT) in women with recurrent stress urinary incontinence - a long-term follow-up. Int Urogynaecol J Pelvic Floor Dysfunct 2001; 12 Suppl 2: S9-11.
  2. Haab F, Sananes S, Amarenco G, Ciofu C, Uzan S, Gattegno B, Thibault P. Results of the tension-free vaginal tape procedure for the treatment of type II stress urinary incontinence at a minimum follow-up of 1 year. J Urol 2001; 165: 159-62.
  3. Kuuva N, Nilsson CG. A nationwide analysis of complications associated with the tension-free vaginal tape (TVT) procedure. Acta Obstet Gynecol Scand 2002; 81: 72.
  4. Ward KL, Hilton P, Browning J. A randomised trial of colposuspension and tension free vaginal tape for primary genuine stress incontinence. Neurourol Urodyn 2000; 19: 386.
  5. Sweat SD, Itano NB, Clemens JQ, et al. Polypropylene mesh tape for stress urinary incontinence: complications of urethral erosion and outlet obstruction. J Urol. 2002; 168: 144-146.
  6. Madjar S, Tchetgen MB, Van Antwerp A, et al.Urethral erosion of tension-free vaginal tape. Urology 2002; 59: 601.
  7. Pit MJ: Rare complications of tension-free vaginal tape procedure: late intraurethral displacement and early misplacement of tape. J Urol 2002; 167: 647.
  8. Volkmer BG, Nesslauer T, Rinnab L, et al. Surgical intervention for complications of the tension-free vaginal tape procedure. J Urol 2003; 169: 570-574.
  9. Jorion JL. Endoscopic treatment of bladder perforation after tension-free vaginal tape procedure. J Urol 2002; 168: 197.
  10. Baracat F, Mitre AI, Kanashiro H, et al. NI. Clinics 2005; 60: 397-400.
  11. Kielb S, Clemens J. Endoscopic excision of intravesical tension-free vaginal tape with laparoscopic instrument assistance J Urol 2004; 172: 971.
  12. Giri SK, Drumm J, Flood HD. Holmium laser excision of intravesical tension-free vaginal tape and polypropylene suture after anti-incontinence procedures. J Urol 2005; 174: 1306-7.
  13. Hodroff M, Portis A, Siegel SW. Endoscopic removal of intravesical polypropylene sling with the holmium laser. J Urol 2004; 172: 1361-2.

Correspondence to:
Stavros N. Charalambous MD PhD FEBU
Urological Surgeon
Vice-Director of Urological Department
Hippokratio General Hospital
49 Kostantinoupoleos str
55236, Thessaloniki, Greece
Tel. +3023 10892307 - Fax +2310 30 826666
E-mail: st.charalambous@gmail.com